Prior Bankruptcy?

Y

N

Your First and Last Name

First Name

Last Name

Primary Contact Phone

(###)

###

####

Secondary Contact Phone if any

(###)

###

####

Are you *

Single

Living with Partner

Married

Separated

Divorcing

Divorced

Widowed

Spouse's Name

Whether you're filing Jointly or have a Non-Filing spouse, you Spouse's name is required.

First Name

Last Name

Spouse/Partner's Contact Phone

(###)

###

####

Do you and your spouse live in separate households?

Y

N

Dependents?

Y

N

Are you a sole proprietor, shareholder, partner or investor in any business(s)?

Y

N

Do you Receive Unemployment?

Y

N

Receive Social Security?

Y

N

Pension?

Y

N

Annuity?

Y

N

Pay Child Support?

Y

N

Receive Child Support?

Y

N

Have another income? Examples: rentals, oil/gas royalties, gifts, etc.

Y

N

Have you made a distribution(s) from a 401K or IRA in the last 7 months?

Y

N

Do you have interest in a Trust?

Y

N

Do you have a Mortgage?

Y

N

If Yes, are you Current on Payments?

Y

N

If Not Current, Can you catch up Arrears within a Month or so?

Y

N

Do you own Rental Property?

Y

N

Do you own Land/Lot(s) or have any other interest(s) in Land?

Y

N

Do you Rent where you live?

Y

N

Are you current on Vehicle Payments?

Y

N

Retirement Account(s)

Y

N

Stock

Y

N

Savings

Y

N

Other Accounts/Valuable Assets (if yes, please describe - include valuable art, guns, jewelry, heirlooms, etc.)

Y

N

Are your Debts primarily

Personal

Business

Is any Loan secured by Household items?

Y

N

Name

First Name

Last Name

Name

First Name

Last Name